Metrics are essential for quantification of the success of any quality improvement process. The choice of metrics appropriate to the needs of the institution is essential and may pose a barrier with regards to quality improvement application to pressure ulcers. This is simply due to the existence of many varying measurements. It is important for the organization to choose a few easily measured metrics and not to use all of the metrics outlined below to avoid an overload of data which is not meaningful or useful. Assignment of the metrics may prove challenging as opinions differ among caregivers as to the importance of the various metrics.
To determine which ones are appropriate, first decide upon the number of metrics to measure, generally no more than three to five. Decide whether the need is metrics specific to the facility, to the unit, or to patient. The table below will assist in selection of metrics based upon this concept. Narrow the field based upon the General Aims set up by the organization. Rank order the metrics by importance and finalize the decision based on the rank order. The process is as follows:
The tables included below are divided below into measurements generally considered by applicability to facility or to the individual patient. Facility specific and unit specific metrics are used in tracking performance of the institution overall and of targeted units.
Patient specific metrics are applicable to everyday treatment and to tracking over time since many of those patients who suffer from complicated Stage III and IV wounds require multiple hospital stays., They are especially important in relationship to transitions for patients who go to post acute care hospitalization or skilled nursing facilities. Consistent use of metrics enables the caregiver to track progress more effectively and to recognize success or identify areas for further improvement.
Prevalence and incidence
See cSSSIs Resource Room Pressure Ulcer Education Resources for an example of survey results.
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To measure the number of pressure ulcers that are acquired in the hospital and to quantify a percentage of the population that has hospital acquired pressure ulcers.
Address quarterly report vs daily report
Prevalence- spots days per month
Progression of wounds. How to include stage 1 and 2. |
Acquired from documentation |
A chart review to investigate the number of pressure ulcers that have been acquired during a patient’s hospitalization. |
Case mix comparison |
Comparison of the case mix index with the rate of pressure ulcer |
Discharge destination |
Tracking via the discharge instruction sheet to document pressure ulcers found on repeat admissions that may have been acquired at other facilities |
Mortality |
This metric is to quantify the number of deaths that are associated with sepsis |
Surgical procedure |
Tool to measure which surgical procedures are more prone to pressure ulcer development so that a pressure ulcer prevention measure may be implemented to decrease occurrences. |
Cultured organisms |
Culturing of wounds to document the most prevalent organisms found in pressure ulcers to help develop more effective treatment options to decrease risk of mortality and complications |
Wound assessment on admission yes or no, formal assessment
http://www.npuap.org/resources.htm |
Evaluate the patient for pre-existing wounds. The wounds would be measured and staged on admission. This information can be used to monitor how many ulcers have worsened, stayed the course or improved during hospitalization. |
Risk assessment on admission combine with Braden score
http://www.bradenscale.com/ |
A measuring tool to help predict which patients are at risk for developing a pressure ulcer so pressure ulcer prevention measures can be implemented to decrease hospital acquired ulcers. The Braden score is the preferred scale for risk assessment. |
Wound assessment on discharge |
Evaluate the patient for any hospital acquired ulcers and to document the ulcers measurements and staging on discharge. |
Risk assessment on discharge |
A tool to determine if the patient will have any further needs for discharge planning such as orders for other facilities for prevention or home equipment for management and prevention of ulcerations (specialty beds) |
Unit/MD specific data |
Document the incidence and prevalence of hospital acquired pressure ulcers by nursing unit and also by service. This information will help to “target” high risk areas that may need additional staff education and prevention protocols. |
Co-morbidity conditions |
To track which co-morbidity conditions which may place a patient at risk for pressure ulcers and these patients would then be placed on the prevention protocol due to their diagnoses. |
Prevention Interventions. Initiate Prevention protocol. |
Initiate prevention protocol. This is to measure whether or not the prevention protocol was initiated on patients who have developed a hospital acquired pressure ulcer and if not, it would indicate an educational opportunity for ulcer prevention. Once the protocol is initiated, the patients would need to be tracked on which interventions were implemented and then track which patients acquired a pressure ulcer during hospitalization. This tool can be used as a check and balance to make sure our protocol is up to date and effective.
The tracking of preventative interventions such as turning schedules, order sets, nutritional evaluation, and skin care protocols will have increasing importance as facilities as asked to be more proactive, needing to produce proof of plans to prevent pressure ulcer formation. |
Location of Pressure Ulcer |
Along with other descriptive measurements, location becomes an important parameter for measurement since it may be predictive of a need for corrective action. For instance, the occurrence of occipital pressure ulcers suggests the need for a more aggressive turning schedule and repositioning. |
Number of Pressure Ulcers |
The number of pressure ulcers per patient may be monitored along with incidence and prevalence. This is significant since the presence of a pressure ulcer is a significant risk factor for the development of additional pressure ulcers. |
Treatment interventions |
- 1. Stage the ulcer
- Stage 1: preventive measures and dressed with transparent films for protection
- Stage 2: occlusive or semi-permeable dressing, avoid wet-to-dry dressings
- Stages 3 and 4: treatment of wound infections, debridement of necrotic tissue
- 2. Assess nutritional status
- Nutritional intake assessed by a nutritionist
- Include protein and caloric intake, hydration status, serum albumin and/or pre-albumin, and total lymphocyte count
- Correction of nutritional deficiencies
- 3. Mattress and tissue pressure relief
- Non-powered support surfaces (ex. foam): if the patient can assume a variety of positions without bearing weight on the ulcer
- Overlays are additional support surfaces (ex. foam, air, or water): for patients who can assume a variety of positions without bearing weight on the ulcer
- Powered or dynamic support surfaces (ex. alternating pressure mattresses, low air loss beds, and air fluidized mattresses): when the patient cannot readily be repositioned, has a large ulcer or ulcers at multiple sites, or if the pressure ulcer does not show evidence of healing
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Pressure redistribution type |
Redistribution of pressure is often referred to as “off loading” and may be tracked using turning schedule, use of specialized beds, positioning, and repositioning. Physical Therapy and Occupational Therapy consultation may be useful for assisting in redistribution of pressure. |
Microclimate interventions (moisture, friction, heat) |
Moisture control and friction reduction may be documented using the rate of catheter use, rectal tube use which should be noted in order sets or in nursing documentation of tubing and lines now generally recommended as a separate charting. Most data collection is difficult on this topic due to nonstandard formats for charting and variety of treatments including use of drying agents.
Increase moisture has been identified as a cause of pressure ulcers. The patient should be evaluated for incontinence of bowel and bladder and preventative measures should be in place such as routine checks for moisture and use of moisture barriers. Also the patient should have skin folds assessed and have appropriate care of skin folds such as routine cleaning and drying of the folds to prevent breakdown. |
Nutrition |
Assessment of nutritional intake by a nutritionist to include protein and caloric intake, hydration status, serum albumin and/or pre-albumin and total lymphocyte count. The goal would be to correct the nutritional deficiencies to promote wound healing. |
Turning schedule |
The schedule for turning the patient is most easily measured by nursing documentation. Generally an every two hour schedule has been considered standard although some facilities are now using an hourly turn schedule. |
